Chlamydia : epidemiology & control. Russell Waddell
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1 Chlamydia : epidemiology & control Russell Waddell
2 What Are the Strongest Predictors of Chlamydial Infection? Young age Under 25 years Sexual activity risks No. of partners Partner selection/network Clinical signs (cervicitis, urethritis, etc) Prior chlamydial infection
3 Five trends in Chlamydia Epidemiology First - two epidemiological profiles Scandinavia and Canada Introduce control program and decline followed by rise Aust USA UK Introduced control program 1995 and notifications rose, no initial decline Brunham STI Jan 2008
4 60000 Notification of chlamydia Aust South Australia
5 Notification of chlamydia Notifcations of chlamydia in South Australia by sex Male Notifications Female notifications
6 Chlamydia and Prevention Improved diagnostic tests (DNA amplification) - Improved sensitivity for C. trachomatis - Novel specimens (urine, self-obtained swabs) Expanded screening (clinical, non-clinical settings) - Convenience specimens eg urine - Women pelvic exam not required. - Males urethral swab not required.
7 Why is it increasing? Related to testing Increased testing Only (small) part of the story False positives Specificity->99.7% Fewer False negatives More sensitive tests more positives minor contribution 30% increase attributable to the introduction of NAAT
8 450.00% % Change in testing and notifications for females from average of % % % % % % % 50.00% 0.00% %change positives %change tests Year (q) Percentage change
9 % Change in testing and notifications for males from average of % 400.0% CHANGE POSITIVES %CHANGE TEST 350.0% 300.0% 250.0% 200.0% percentage 150.0% 100.0% 50.0% 0.0% Year (q)
10 Five trends in Chlamydia Epidemiology Second Increase in re-infection rates Consistent with the impaired immunity hypothesis Canada 1995 <5 case repeat infections per 100,000 population to 50 reinfections /100,000 population in 2003 SA in % of notifications were re-infections % women & 14% men were repeat notifications
11 Five trends in Chlamydia Epidemiology Brunham RC JID 2005:192,1836
12 Five trends in Chlamydia Epidemiology 400 Female male Notification of second infection
13 Five trends in Chlamydia Epidemiology 18.00% 16.00% 14.00% 12.00% Female repeat infections Male repeat infections Repeat infections as a percentage of total 10.00% 8.00% 6.00% 4.00% 2.00% 0.00%
14 Female :male testing ratio Statewide Female:Male Ratio Clinic 275 Female:Male Ratio
15 Arrested immunity Natural immune reaction clears the infection in 1-3 years CT only induces protective immunity over time PID and infertility largely a consequence of immune reaction tubal damage is an immunopathy Tubal preg, ectopic preg result of re-infection in immune individuals Incidence decreases with age Increased Immunity over time Decreased ectropion biological susceptibility CSWs - Incidence decreases with the duration of sex work
16 Arrested immunity Treatment early in infection leads to leads to arrested immunity Under this hypothesis the expectation would then be for increased risk of re-infection increase in detectable cases particularly repeat infections decrease rate of PID, ectopics and tubal infertility
17 Five trends in Chlamydia Epidemiology
18 Five trends in Chlamydia Epidemiology Third Ectopic pregnancy and tubal infertility rates, where measured, have declined despite increasing notifications of chlamydia
19 Five trends in Chlamydia Epidemiology Fourth Selection pressure Sweden screening test and treat evolutionary response usually antibiotic resistance Evolutionary escape from detection method rather than the treatment.
20 Why is it increasing? Antibiotic resistance No direct evidence but few centres do culture no laboratory routinely cultures in Australia Clinically treatment failures are rare
21 Five trends in Chlamydia Epidemiology Five Reduction in size of sexual networks over time (Manitoba) This should lead to increased control and a decrease in chlamydia infections Networks with fewer members, lower immunity and increased number of cases
22 Local network motifs Bearman, Moodey and Stovel Forthcoming in AJS (With permission from P. Bearman)
23 Standard Strategies for Chlamydia Prevention Treatment of infected persons - Symptom recognition - Clinical training of providers - Prompt access to low cost (or cost-free) treatment services Case-finding - Female screening - (Males presumed symptomatic) - Partner referral Treatment of infected persons sex partners
24 Further Strategies for Chlamydia Prevention Enhanced Screening There is a significant push for more screening of Australian communities. However screened and treated individuals are then returned to a sexually active pool with untreated infections. Need very high level of screening and treatment to sustain reduction
25 Further Strategies for Chlamydia Prevention Standard partner notification Increased resources for public health personnel, Patient inform and refer his/her partners Treatment by public health staff in the field Patient-delivered therapy to partner(s) Many clinicians do it anyway azithromycin is a benign drugs (safer than metronidazole) Legal barriers may be less common than believed by clinicians and health authorities Pharmacy-facilitated expedited treatment
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